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Thank you for joining us today!. Please dial 1.800.732.6179 now to connect to the audio for this webinar. To show/hide the control panel click the double arrows. Presentation by Christopher Millett and Brian Hutchison Wednesday, September 23, 2009. What is pay for performance?.

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Thank you for joining us today

Thank you for joining us today!

Please dial 1.800.732.6179 now to connect to the audio for this webinar.

To show/hide the control panel click the double arrows.


Thank you for joining us today

Presentation by Christopher Millett and Brian Hutchison

Wednesday, September 23, 2009


Thank you for joining us today

What is pay for performance?


What is pay for performance

What is pay for performance?

  • Providing financial incentives to health plans or providers for meeting performance targets set by payers – i.e. insurers, government


P4p programs vary considerably

P4P programs vary considerably

  • Bonus, penalty, auto-assignment

  • Reward achievement or improvement

  • Size of incentive (2–30% of income)

  • Quality measures used

    • Process or outcome

    • Preventative, CDM

  • Risk adjustment


Comprehensive p4p in the u k quality and outcomes framework qof

Comprehensive P4P in the U.K.Quality and Outcomes Framework (QOF)

  • 25% of practice income from a complex set of incentives

  • 3 domains; chronic disease management, practice organization, patient experience

  • 1050 points (1 point = CA$220)

  • 550 clinical domain points

  • 356 points = CVD + diabetes


Diabetes qof 18 indicators

Diabetes QOF (18 indicators)

DM 2 The percentage of patients with diabetes whose

notes record BMI in the previous 15 months

(3 points – threshold 40-90%)

DM 8 The percentage of patients with diabetes who have

a record of retinal screening in the previous 15 months

(5 points – threshold 40-90%)

DM 6 The percentage of patients with diabetes in

whom the last HbA1C is 7.4 or less in last 15 months

(17 points – threshold 40-50%)


Selective p4p the ontario example

Selective P4P - the Ontario example

Focused on activities (outputs) rather than quality (processes) of care

Output incentives primarily address access concerns

P4P incentives are available to physicians participating in patient enrollment models

Mix of incentives varies across payment models


Process of care incentives

Process of care incentives

Graduated bonuses for achieving target

levels of provision of preventive services to

enrolled patients:

Pap smears

Mammograms

Influenza vaccination

Childhood immunization

Colorectal cancer screening


Examples of output incentives

Examples of output incentives

Payments for providing priority services above threshold levels (e.g., obstetrical deliveries, palliative care, minor surgery, home visits, hospital care, and care of patients with chronic mental illness)

Fees for contacting patients to schedule appointments for screening and prevention

Fees for enrolling unattached patients

Fee for completion of diabetic care flow sheet

Premiums for after-hours care

Add-on smoking cessation counseling fee


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What is the evidence that pay for performance has worked?


What is the evidence that pay for performance has worked

What is the evidence that pay for performance has worked?

  • Evidence remains limited

    Christianson JB. Med Care Res Rev. 2008

    Petersen LA. Ann Intern Med. 2006

  • Difficult to disentangle P4P from other quality initiatives and secular trends

  • Evaluation of U.K. scheme ongoing


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Are there unintended consequences?


1 potential adverse impact on disparities

1. Potential adverse impact on disparities

Millett C. Diabetes Care 2009


2 exclusion of sicker patients

2. Exclusion of sicker patients

California P4P (McDonald, Annals Family Medicine 2009)

“I told someone, you’re killing my pay for

performance. Go join another medical group”

U.K. P4P

Exception reporting

Older patients, women, those with comorbidity

more likely to be excluded (Simpson, BMC Fam Prac. 2007)


3 neglect of non incentivized care

3. Neglect of non-incentivized care?

  • Aspects of care that were not incentivized in the U.K. P4P declined for patients with asthma or heart disease between 2005 and 2007

    Campbell et al. N Engl J Med. 2009


4 undermining intrinsic motivation

4. Undermining intrinsic motivation?

For complex tasks, extrinsic incentives tend to reduce intrinsic motivation and performance unless they are consonant with personal and professional interests, values and sense of self

Deci et al.Psych Bulletin 1999

Gagné and Deci. J Org Behavior 2005


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What are the prerequisites for implementation?


What are the prerequisites for implementation

What are the prerequisites for implementation?

  • Money

  • Professional involvement and sign-up

  • High penetration of HIT

  • Patient enrolment (to establish denominators)


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Does it deliver value for money?


Does it deliver value for money

Does it deliver value for money?

  • Difficult to evaluate as “savings” derived from improved quality take time to accrue

  • Bigger picture in U.K.:

    - Importance of investing in primary care

  • Unanswered research question: Does P4P produce incremental benefits in the presence of ongoing performance feedback and quality improvement support?


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For more information on this or future sessions please visit www.chsrf.ca/researcheroncall


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